Sept. 1894.] JOUBERT ON ABDOMINAL SURGERY. 321

?riptat fommitniqatiaits. \

ABDOMINAL SURGERY AT THE EDEN

HOSPITAL, CALCUTTA, DURING THE

YEARS 1892 AND 1893.

By Surgn.-Lieut.-Col. C. H. Joubert, m.b., Lond., f.r.c.s

Obstetric Physician, Mcdical College, Calcutta. yL-'j (Continued from page 290.)

The following details of the cases operated upon in 1 893 are of interest:?

Multilocuiar Ovarian Cyst. Case No. 1.

?This patient was a Kassia, sent to Calcutta from Assam for operation, a strong, vigorous hill woman, showing no signs of other organic disease than the tumour. The main cyst was opened and some secondary cysts had been broken down, 418 oz. of thick fluid being evacuated, and 1 was about to deal with some firm omental adhesions at the

upper part of the tumour when the pulse sudden-

ly failed, followed by cessation of respiration. I

had just enlarged the incision upwards, and at the same moment that the cliloroformist gave warn-

ing of danger I noticed the cut tissues become pale and all bleeding stop. In spite of continued efforts respiration could not be re-established. The post-mortem examination showed no organic disease. The heart was quite healthy, only rather large, as is usual with hill people used to steep ascents. The death was due to heart failure

while under the influence of chloroform, aggra- vated no doubt by the loss of vascular tension due to the removal of the large amount of fluid from the tense cyst. Dermoid Ovarian Cyst. Case No. 2.?This

was a child of under ten years who had never

menstruated. She was first brought to me in October 1891, when her father stated that a small

lump, noticed in the abdomen four months pre- viously, had been growing rapidly. A rounded

tense cystic tumour, extremely movable, was

found, having apparently, by rectal examination, no pelvic connection. Thirteen oz. of clear,

limpid, orangerred fluid were withdrawn by the aspirator, very albuminous. The cyst collapsed and disappeared and was diagnosed as omental. She came to hospital again in February 1893, being then nine years and three months of age, as the tumour had reappeared. The abdomen was

opened and a cyst with a long pedicle from the left broad ligament removed. It contained 26

oz. of yellow fluid and the cyst weighed 2 oz. At

the base of the cyst was a solid part containing sebaceous matter and a quantity of hair.

Multilocular Ovarian Cyst. Case No. 3.?

The tumour in this case was chiefly nourished by very vascular large omental adhesions, the pedicle being no thicker than the little finger. It weighed 6 lbs. after all secondary cysts that could be were broken down.

Multilocular Ovarian Cyst. Case No. 4? An ordinary large ovarian tumour presenting practically no difficulties in its removal.

Dermoid Ovarian Cyst. Case No. 5.?The tumour was small and had to be pushed up out of the pelvis per vaginam by an assistant. It contained only 4 oz. of fluid, but a large lock of black hair 18 inches in length and a lump of bone like the front of an astragalus, studded with

very perfect molar teeth, some loosely attached, some just appearing at the surface of the bone.

Double Ovarian Cysts, Multilocular. Case No. 6.-?I saw this girl a year before the operation and diagnosed a small left ovarian cyst, and advised operation. At the operation both ovaries were found to be cystic, containing 8 oz. of fluid on the left side and 4 oz. on the right. Multilocular Ovarian Cysts, Double. Case

No. 7.?The abdomen in this case appeared to contain a number of tumours, reaching from pelvis to the ribs, some apparently cystic, some solid, movable on each other, but connected

deeply. On opening the abdomen the tumour had the appearance of a lobulated fibroid, which had become cjrstic in places. Some upper omental adhesions were tied and cut through and the mass brought outside the abdomen. Under the impression that the growth was of uterine origin I placed an elastic ligature round the base and a serre-noeud in position. But noticing that there was still a considerable independent mass in the right flank, I passed in}*- hand again into the abdomen and brought out a second large lobulated cystic tumour, having a good pedicle from the right broad ligament. This, being clear- ly an old multilocular ovarian tumour, was re- moved en masse, after securing the pedicle. On examining again very carefully the first tumour brought to the surface, I found it to be ovarian in close contact with the uterus, the left cornu of which had become spread out on its inner lower angle, giving the appearance of a fibroid growing from the left back of the uterus. The elastic ligature and loose serre-nceud were re-

moved, and after extreme difficulty a good pedicle to the left tumour was secured by a triple lock- ing ligature. Hie broad base of the tumour consisted of several cysts which had to be punc- tured, one by one,?a pedicle gradually deve- loping as the cysts collapsed. Fortunately the chief vascular supply had come from the omen- tal connections at the upper part of the tumour, and there were no large vessels in the broad base or coming from the uterus. Most of the cysts contained papillomatous matter. It should be noted that the patient had noticed the exist- ence of a tumour for eight years. The foregoing seveu cases were all the true

Dvarian cystomata that were operated upon during the year 1893, and the only death was

46

322 INDIAN MEDICAL GAZETTE. [Sept. 1894.

from chloroform in a case in which there was

every reason to anticipate a successful result. The next eight cases in the series were of

parovarian cysts, usually included under the head of ovariotomies, although in some cases, where the cysts are shelled out of their bed in the broad ligament, the ovaries are not removed but remain behind on the collapsed peritoneal coat of the cjst. In four of the eight cases the ovaries remained behind untouched in this way. In such cases, although the peritoneum is twice cut through, (1) the parietal layer in the abdo- minal incision and (2) the visceral layer covering the tumour, yet the removal is effected extra-

peritoneally and no stump or pedicle is usually dropped back into the peritoneal cavity, the

edges of the cut sac from which the cyst has been removed being stitched to the abdominal incision.

Parovarian Cyst. Case No. 8.?This patient was in hospital in July 1892, when a cyst in the region of the right ovary was detected and

tapped vaginally. She was again admitted in

August and in November for painful irregular menstruation and constant pelvic pain. On re- admission in December 1892, a large well-defined cyst was found on the right side, reaching nearly to the umbilicus and displacing the pelvic organs. On opening the abdomen a thin walled cyst was found in the layers of the right broad ligament, continuous with the uterus internally and dip- ping deeply into tiie depths of the pelvis. The

Fallopian tube was stretched out over it, and there were omental adhesions as well as pelvic. Tupping removed 2-ioz. of clear fluid. Shelling out the cyst was then coinemenced, but had to be abandoned on account of the extremely thin posterior wall tearing during the process. The

cub edges of the cj^st were therefore trimmed

and stitched to the lower part of the abdominal wound, the cavity being stuffed with iodoform

gauze round a glass drainage tube. From the first after the operation the patient

was very restless and boisterous, tossing about, tearing off her dressings, striking the nurses and trying to get out of bed. She had an unhappy home, and had accepted operation, I learnt, in hopes of death while under chloroform. When

she came to and found herself alive she said she

would kill herself and she succeeded, for perito- nitis set in and she died 48 hours after the

operation. The post-mortem showed general purulent

peritonitis, but no haemorrhage or accident of

any kind at the seat of operation. There was

no sign of peritonitis at the time of operation. The purulent lymph was very virulent and gave dissection sores to both my Resident Surgeon and myself. Double Parovarian Cysts, Case No. 9.?

This was a school-girl of 19 years, and the only

history given was that a tumour had been noticed in the abdomen three weeks previous to admis- sion. A soft fluctuating tumour reaching to the umbilicus and distinctly double was f->und, the cervix being pushed to the right by the lower part of the tumour. Diagnosis, parovarian cyst, probably double. On opening the abdomen two cysts were found, the right one reaching the

highest with a moderate-sized pedicle ; the left one pressed down into the pelvis by the other and dipping deeply between the layers of the left broad ligament. The right cyst was tapped, and 16 oz. of thin yellowish fluid removed. It was removed without difficulty after separating some omental adhesions, a good pedicle being secured. The left cyst was then tapped and 16 oz. of thicker claret-coloured fluid removed. The base of the collapsed cyst was so broad and deep- ly situated that a safe pedicle seemed impossible to be secured. The actual cyst was therefore shelled out of its peritoneal coat, and the broad remaining base could then be made into a safe pedicle and secured by a triple-locking ligature. Both c}rsts were unilocular, and on the walls of each was found the ovary thinned and flattened out.

Parovarian Cyst. Case No. 10.?There was a history of three years growth and the abdomen was enormously distended by an apparently un- ilocular cyst. On opening the abdomen and exposing the

cyst, the trocar drew off 612 oz. of clear watery fluid. On drawing out the collapsed cj7st the base appeared to be very broad, but this was

chiefly due to a large adherent coil of intes- tine. On separating this a pedicle which could be secured by a Staffordshire knot was obtained and the cyst removed. On its posterior wall was found the healthy left ovary. The right tube and ovary were healthy. The left tube was

spread out and lost on the wall of the cyst. The cyst was unilocular, developing apparently from a straight tube of the parovarium. It

weighed 18 oz. and its peritoneal coat could be stripped off with ease.

Parovarian Cyst. Case No. 11.?Tumour

only noticed for three months. On admission it was found reaching to the umbilicus, very lax and movable. On opening the abdomen a parovarian cyst,

as diagnosed, was found in the folds of the left broad ligament. The base was as broad as the widest circumference of the cyst, the tube being stretched out over the cyst. The uterus was

high up and in close coutact with the right side of the cyst. Tapping removed 20 oz. of thin brownish fluid. The actual cyst was shelled out of its peritoneal covering with some difficulty. The ovary (left) was found to be normal and on the posterior peritoneal wall of the cyst. The

tube (left) was distended with thin clear fluid.

Sept. 1894.] JOUBERT ON ABDOMINAL SURGERY. *

323

The cut edges of the remains of the tumour were stitched to the lower part of the abdominal wound and its cavity stuffed with iodoform gauze round a glass drainage tube.

Pelvic Cyst, probably Parovarian but of Hemorrhagic Nature. Case No. 12.?This was a most interesting case. The history given and condensed is as follows:?Age 30, nullipara. Menstruation always regular till two years ago, when there was menorrhagia till March 1892, when it stopped suddenly with much pelvic pain for a month subsequently. Occasional pain since. Noticed a tumour in the left iliac fossa in August 1892. On admission on 3rd April 1893 the lower abdomen was found occupied by a prominent tumour, chiefly left-sided but reaching to two fingers' breadth above umbilicus on the

right. Outline irregular, tense and cystic in places, slightly movable only. Uterus below right base of tumour, sound entering 2? inches with diffi- culty; posterior and left culs occupied by base of tumour, where it is fixed. On the 6th April the tumour had entirely dis-

appeared, the abdomen was lax and tympanitic in front, flanks dull from free fluid to level of the anterior superior iliac spines. Per vaginam, culs clear, uterus central and freely movable. The cyst had evidently ruptured. Patient's gene- ral condition excellent, no disturbance whatever. She now stated that the tumour had appear- ed and disappeared in this way seven times

previously. There was, however, present very marked cardiac disease :?Hammer pulse, athero- matous arteries, marked double aortic and mitral murmurs, increased area of cardiac dulness. Urine normal. Although removal of the ruptured cyst seemed to be called for, the condition of the heart and the history of previous ruptures, made me decide to wait and watch the case. By the 11th April?five days?all trace of fluid

in the peritoneum had disappeared, without the occurrence of a single bad symptom. On the 22nd April the tumour was found to

have reappeared, similar to its former condition. It increased in size till the 25th April, causing much pain and tension, but it ruptured again with relief to the patient in the afternoon of that day. On the 26th the flunks were again dull and there was distinct thickening in the vaginal culs this time. By the 2nd May the tumour had again formed

reaching to just above the umbilicus, painful, hard and tense. I got the present Principal of the Medical College, Dr. Bomford, who had been on the Hyderabad Chloroform Commission, to

examine the patient with reference to the ad- ministration of chloroform, and he gave his

opinion that it might be given. The abdomen was therefore opened under

chloroform on the 14th May; and not to refer

again to this point I may say that the patient took chloroform very well, and that at no time

was there the least apparent failure either of the heart's action or of the respiration. A tumour

growing from the left broad ligament was ex- posed. It was red and flesh-coloured except at one spot anteriorly, where, the wall being thinner, it was more like an ordinary cyst. The peri- toneum was intimately adherent to the growth and not movable over it. An examination of its relations showed that starting from the left side of the uterus, which was pushed over to the right, it separated widely the two layers of the left broad ligament, filled the left half of

the pelvis and rose to half way between the

anterior superior iliac spine and the umbilicus. There was an adherent piece of large intestine, sigmuid flexure and rectum, coursing trans-

versely downwards from left to right on its

posterior wall. Perhaps a better description would be that the tumour burrowed beneath this piece of the gut. A small Tait's trocar was inserted and 36 oz. of brownish opaque fluid withdrawn. On enlarging the opening in the cyst for the

purpose of shelling it out of its bed, clots of blood and decolorised fibrin escaped. The fingers were then introduced into the cyst and more clots and pieces of laminated whitish fibrin removed. From below the fibrin in one place some curious- looking tissue was peeled off the inner wall of

the cyst. To the naked eye it appeared almost like placental tissue, being firm, hard and brittle. (Subsequent microscopic examination showed this tissue to be of sarcomatous nature.) Free bleed-

ing now occurred from the interior of the cyst, but it was arrested by the injection of hot

water. The walls of the cyst proving to be so vascular and friable, breaking down with free

bleeding, the project of shelling out was aban- doned. Indeed, the cyst walls at this stage resembled those of a gestation cyst or of a pyo- =?alpinx. With the collapse of the cyst the piece )f large intestine on the posterior wall came into pery close relation with the opening in the cyst, md when the edges of the opening in the cyst lad been stitched to the lower edges of the ab- lominal incision the piece of gut was in contact vith the anterior abdominal wall, but a piece of >mentun was pulled down and interposed be- ,vveen the two. The cavity of the cyst was then tuffed with iodoform gauze round a drainage ube and no further bleeding occurred. The

?peration did not clearly prove the nature of the ;rowth, beyond that it was in the folds of the >road ligament. Against the theory of its being , gestation cyst originally?tubal which had rupt- ured into the broad ligament?was the fact that he woman had never conceived or at least said he had not. But in favour of it was the fact of he sudden cessation of menorrhagia in March 892, fourteen months before the operation. Could

, gestation cyst have persisted for so long, rup- uring and refilling and rupturing again nine or

324 INDIAN MEDICAL GAZETTE. [Sept. 1894.

ten times ? It could hardly have been a papil- lomatous parovarian cyst as the peritoneal cavity was absolutely free from any trace or sign of papillomatous growths. But there Was a growth of tissue of sarcomatous nature on the inner

walls of the cyst, and haemorrhage recurring from the free surface of this would account for the symptoms. The subsequent history of convalescence was as

follows:?15 th May.?About loz. of bloody fluid removed from the tube. 16th May.?About loz. of similar fluid and dressings soaked. 17th May. ?About 2 drs. only of dark fluid from tube. Gauze removed from cavity and fresh inserted. 18th

May.?About 3 ozs. of pale fluid from tube. 19th

May.?2 drs. of dark fluid ; gauze changed. 20th

May.?6 drs. of similar fluid. 21 st May.?Gauze changed and tube not reinserted. Up to date no clots or anything else have been washed out of cavity when the gauze was changed. From this date the washing and stuffing of cavity were dune daily, with diminishing quantities of gauze. Convalescence was normal, except for

slight right parotitis during first week. The only rises of temperature were to 100?2 on second day and 100?6 on sixth day. When the cavity had filled up a small granulation persisted at the site of the opening into the cyst which bled readily on being touched. The patient left hospital on 28th June and has not since been heard of.

Double Parovarian Cysts. Case No. 13.? The abdomen was greatly distended by a large cystic tumour of irregular outline, which filled the posterior half of the pelvis and dragged the uterus upwards. The sound entered 3^ inches. A history of six months' growth only was given. On opening the abdomen the uterus was found

enlarged and imbedded in the front wall of a

large tumour, which looked at first like a myo- matous out-growth of the uterus. But the

tumour was clearly cystic and thin-walled, con- taining dark fluid on the left side and clear fluid on the right. There were numerous thick

parietal and omental adhesions. The lower part of the tumour on both sides invaded the broad

ligaments. Tapping withdrew 36 ozs. of thin

coffee-coloured fluid from the left side. The

trocar was then thrust into the cyst on the right side through the original puncture in the left

cyst and 62 ozs. of thin yellow fluid withdrawn. After separating and ligaturing the omental and parietal adhesions, the left side of the tumour was found to completely fill the pelvis, obliterat-

ing its cavity, the condition being that there were two large broad ligament cysts, one on each side, which had fused centrally by separating the peritoneum from the back of the uterus after splitting up the layers of the broad ligaments. The intestines were adherent in several places. An attempt to shell out the cysts had to be

abandoned owing to the extreme thinness of the

combined peritoneal and proper cyst walls. An incision into each cyst was therefore arranged, with the septum between the two, and the left side of the incision into the left cyst was sewn to the left edge of the abdominal wound, and the right edge of the incision into the right cyst similarly treated on the right side, shutting off completely the abdominal cavity. The cysts were then stuffed with iodoform gauze and the

upper part of the abdominal wound closed. The operation presented extreme difficulties, and lasted 2-b hours. The patient's condition was fair after the operation, but she became very low the next day and died 23 hours after the operation. A post-mortem examination showed absence of

any haemorrhage or peritonitis, the parts operated upon being in excellent condition, but there was interstitial nephritis and adherent kidney cap- sules, although no albumen had been detected in the urine, though t,he specific gravity was very low?1001. Death was apparently due to ob- scure kidney disease. Double Parovarian Cysts. Case No. 14.?

This patient was a nullipara and the abdominal walls were fat and very rigid, the presence of a tumour being difficult to make out. But under chloroform a central cystic tumour was made out reaching to 1 inch above the umbilicus. The base of the tumour filled the posterior and left vaginal culs and displaced the uterus to the right. One or two small lumps were felt in the right cul. On opening the abdomen a large cystic tu-

mour with a very broad base was found on

the left side dipping down between the layers of the broad ligament. On tapping a large quantity (note of exact amount lost) of thin

yellow fluid was drawn off. There were no ad-

hesions, but a proper pedicle was secured with difficulty, though in the end it could be secured by a Staffordshire knot. The ovary was spread out in a thiu layer on the posterior wall of the cyst. ̂

There was a similar but much smaller cyst on the right side, which was also removed, a pedicle being secured by a Staffordshire knot. The

patient made a normal recovery. Double Parovarian Cysts. Case No. 15.?The

outline of the tumour in this case as felt through the abdominal walls was very irregular. It filled the whole lower abdomen, reaching to 1 inch above umbilicus, filling the posterior and lateral culs and crowding the uterus forwards. I was of opinion that there were probably two cysts. On opening the ab lomen a thin walled cyst

of the left side was exposed. It burrowed exten-

sively between the layers of the broad ligament quite up to the side of the uterus. After tap- ping and removing a large quantity of clear

yellow fluid, an attempt was made to shell the cyst out of the broad ligament. This had to be

abandoned owing to the extreme thinness of the

Sept.

1894

.]

JOUBERT

ON

ABDOMINAL

SURGERY.

325

TABLE C.

Ovariotomy Cases?Eden Hospital, Calcutta, during the year 1893.

No. Date of operation.

10

11

12

13

?fe 14 *<T

30th January 1893

15th February

6th March

6th Sept.

8th Nov.

22nd Nov.

27th Dec.

Parovarian Cysts.

14th January 1893 ..

22nd March ? .,

8th April ?

10th May ? .

15th May ? .

27th Sept. ? .

15

13th Dec.

20th Dec.

Age.

Years.

25

9,*2

30

25

20

25

35

. o c Condition .2 and No.

of children E - o>

t-3

M. 0 para. \ 6"

4" S. A child.

M. 2 para.

M. 6 para.

M. 3 para. 1 abort.

S. single (virgin).

M. lch. ...

30 M. 1 para. I 4 abort. S. 0 para. 19

25

20

30

35

42

20

M. 0 para.

M. 0 para.

M. 0 para.

M. 1 para.

M. 0 para.

M. 3 para.

Adhesions. Ovary re- moved.

5"

3J"

4"

5?"

6"

4"

3"

3|"

4"

5"

Omental above

None

Omental

Omental

None

Slight pelvic ad- hesions.

Omental

Amount of fluid contents and

weight of sac.

Highest tempera- ture after

operation.

Left (dermoid cyst).

Right

Left

Right (der- moid cyst).

Both

Both

5"

5"

Omental and pel- Not removed; vie.

'

sac drained. Omental on right Both

cyst.

Parietal and intes- tinal.

None

Intestinal

Parietal, omental and intestinal.

None

None

Left

Ovary not re- moved; sac shelled out.

Sac not re-

moved, only drained and stuffed with gauze.

Cysts drained and stuffed with iodo- form gauze.

Both

418 ozs.

26 ozs., sac=2 ozs.

152 ozs., sac=61bs.

376 ozs., sac=

3?lbs. 4 ozs., sac=8 ozs.

R=4 ozs., L=8 ozs.fluid. Weight of sac omitted.

R=40 ozs. and sac weighed 13 ozs. L=about 40 ozs. and sac weighed 10| ozs.

24 ozs.

R=16 ozs., L=16 ozs.,sacs=2 drs. each.

612 ozs.,sac=llb. 2 ozs.

20 ozs., sac=2 ozs.

Result.

100"2? on 3rd day.

99*2? on

1st & 2nd

days. 100? on

2nd day. 101? on

3rd day. 100*6? on 2nd day.

99*4? on

th day.

Right

36 ozs.

R. cyst = 62 ozs,, L. cyst=36 ozs.

Notes lost, but large quantity in L. cyst and small in R.

Notes mislaid ...

100* on

1st day. 100? on

5th day.

99" 8? on

3rd day. 101*8? on 5th & 6th days. lOO'G0 on 6th day.

104? just before de a t h, 23 hours after oper- ation.

?

Death du- ring op- eration.

Cure ...

Cure ..,

Cure .

Cure

Cure .

Cure

Death

Cure

Cure

Cure

Name and race. Duration of

disease.

Relieved.

Death

Cure

Panchilong, Kassia

(Bhootan).

Dirabalu Dassi, Ben- gali Hindu.

Mukhi, Bengali Hindu.

Jaliori, Bengali Hindu.

Bhuban, Bengali Hindu.

Miss V., Eurasian ...

Shoiro, Bengali Hindu.

Mrs. C., Eurasian.

Miss T., Eurasian.

Subhi, Hindustani Mahomcdan.

Ameeran, Bengali Mahomedan.

Bama, Bengali Hindu,

Jagatee, Bengali Hindu.

Mrs. R., English

UlOIAIlKS.

2 years .

8 months.

1 year. .

More than 2

years. 4 years

2 years

8 years

This patient died from the effects of chloroform during the operation. A little girl of under 10 years.

Recovery, E. Banerjee, Bengali Christian.

18 months

Only noticed a tumour for 3 weeks 3 years ...

3 months...

8 months...

6 months

2 years

3 years

Double ovarian cysts.

Double ovarian cysts.

(See details as to cause of death.)

Double cysts.

A remarkable case in several respects.

Double cysts.

Double cysts.

326 INDIAN MEDICAL GAZETTE. [Sept. 1894.

combined posterior wall, which gave way in one place. A triple-locking ligature was applied as low down as possible, bub this shut off a little

bit.of the base of the cyst. The tension on the

ligature was considerable, and it would perhaps have been better to have stitched the edges of the cyst to the abdominal wound but for the

tear in the posterior cyst wall low down. The

operation had to be completed rapidly and a small burrowing cyst, the size of an orange with no pedicle, on the right side had to be left un-

touched on account of the bad condition of the

patient. I had to stop several times to allow artificial respiration to be performed, besides which ether was injected several times. But the

patient made a good recovery and took her dis- charge three weeks after the operation.

It will be seen from the above notes how much more difficult to deal with are these cases of

parovarian or broad ligament cysts than true

ovarian cysts, on account of the tendency of the former to burrow downwards into the depths of the pelvis between the layers of the broad liga- ment. In many cases it is impossible to secure a pedicle at all, and in these the cyst has to be shelled out of its peritoneal covering. As a rule the peritoneal coat is loosely attached to the

proper cyst wall and with care the cyst can be shelled out entire. But sometimes the combined wall is so thin in places that it is impossible to separate it into two layers, and the operator finds himself in difficulty. In such cases it is best to stitch the edges of the c}Tst to the abdo- minal incision and treat it by stuffing with

gauze and drainage. The process of obliteration of the sac, however,is very much longer than if, after shelling out the cyst, merely its cellular tissue bed within the peritoneum lias to be obli- terated bv stuffing with gauze and drainage. Though, as a rule, smaller than ovarian cysts, these parovarian cjTsts may attain a great size, as in Case No. 10 where the contents measured 612 ozs. They also cause great distress by their

pressure-effects on the pelvic viscera and they cannot be cured by mere tapping. The removal of large ovarian c\7sts even with numerous adhe- sions is a much simpler operation than the re- moval of moderate-sized burrowing parovarian cysts and is attended with a smaller mortality.